Transcript

1.
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One in five elderly patients discharged
from a hospital is readmitted within 30 days,
according to a HealthAffairs study. And though
many of these return trips are unavoidable—
unexpected complications that arise after the
patients return home, for example—hospitals
can and should prevent many readmissions.
In this FierceHealthcare eBook, we highlight
readmission reduction strategies that hospitals
are implementing before, during and after
discharge to improve care coordination of
vulnerable elderly patients and those with
multiple chronic conditions who may fail to
follow discharge instructions, don’t properly
take medications or don’t arrange follow-up care.
In this eBook, you’ll learn the 12 components
that make up Project RED, a program developed
by Boston University Medical Center to improve
care coordination around patient discharge,
and how social workers coordinate posthospital discharge care for older adults at
Rush University Medical Center in Chicago.
That’s not all. Sacred Heart Hospital in
Eau Claire, Wis. shares how integrated care
helped the facility achieve better patient
outcomes and lower costs. And Tina Paulson,
R.N., nurse manager at the 25-bed Baystate
Mary Lane Hospital in Ware, Mass., reveals
the strategies the community hospital has
employed to reduce patient fall rates in its
critical care and medical-surgical unit.
As Pat LuCore of Sacred Heart points
out, these initiatives help fulfill the
mission that most clinicians aim for when
they enter the healthcare profession:
Providing high-quality care of patients.
Population health management:
How to manage high-risk patients
by Ilene MacDonald
Senior Editor /// Fiercehealthcare
 Thank you to our Sponsor:
3
Four Strategies for Reducing
Hospital Readmissions
6
Discharge Planning
Essentials: Reducing
the Risk of Falls
*Sponsored Content*
7
Improved Discharge
Planning Combats Patient
Readmissions
9
Q&A: How Baystate
Mary Lane Hospital
reduced patient falls
13
Integrated care: It’s Not
Only Possible, It’s Essential
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Four Strategies for Reducing
Hospital Readmissions
By He ather Lindse y
Penalties levied through
the Centers for Medicare &
Medicaid Services (CMS)
Hospital Readmission
Reduction Program, are “on
everyone’s radar screen,”
says Michael Henderson,
M.D., chief quality officer
for Cleveland Clinic Health
System, a nonprofit
multispecialty academic
medical center in Ohio.
“[They’ve] made everyone pay
more attention to reducing
readmission rates.”
As a healthcare provider,
“you never want patients to be
readmitted,” says Cheryl Bailey,
R.N., chief nursing officer and vice
president of patient care services at
Cullman Regional Medical Center, a
145-bed facility in Cullman, Ala. “It
hurts them and the bottom line of
the hospital.”
Fortunately, four strategies can
help hospitals reduce the number of
patients who return for more care
within 30 days of discharge.
“You never want patients to be
readmitted. It hurts them and the
bottom line of the hospital.”
-
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Cheryl Bailey, R.N., chief nursing officer, vice
president of patient care services, Cullman
Regional Medical Center, Cullman, Ala.
1.Improve patient
communication and
education
Communication breakdowns
surrounding the discharge process
“happen every day in every
hospital, and they put patients at
risk for readmission,” says Bailey.
While healthcare providers deliver
discharge instructions, patients are
often focused on heading out the
door, as they are ready to go home
and are not carefully listening to
what’s being said, she says.
Moreover, primary caregivers
often aren’t in the room, and any
questions they may have about
medication can be difficult for
patients to answer once they’re
home, says Bailey.
To reduce readmissions, hospitals
should consider starting patient
education long before discharge.
For example, Sacred Heart Hospital,
a 250-bed center in Eau Claire,
Wis., established a pilot program
requiring healthcare providers to
begin teaching patients at admission
about taking care of their disease
at home. “This way information
isn’t completely new to them at
discharge,” says Julia Lyons, the
hospital’s quality resources director.
Since implementing the program,
patients tend to have fewer
questions during hospital follow-up
calls. Sacred Heart Hospital has
reduced readmissions by about 15
percent since last year, although
this can’t be attributed to any one
initiative, Lyons says.
In addition to educating them
about their medical conditions, tell
patients who to call if they have
questions about their medication,
says Marcia Colone, Ph.D., system
director of care coordination and
clinical social work at UCLA Health
System, which includes two medical
centers, a psychiatric hospital, a
children’s hospital and a medical
group in Los Angeles, Calif.
Education about medications
should address how to fill
prescriptions, when and how to
take drugs and the importance
of adherence.
Medications can be especially
confusing to patients if they have
a new diagnosis, Lyons says.
However, conducting a medication
reconciliation and sending patients
home with a full list of the drugs
they should take can help avoid any
problems, she says.
Hospitals also need to provide
patients with detailed information
about their follow-up appointments
and tell them what to do if their
condition changes, Colone says.
“You have to be sure they know
how to contact their primary care
doctor and what they should do
if they don’t get a response right
away,” she adds. Patients need
access to a live person at the
physician’s office, rather than a
recording, so they can describe their
red flag symptoms.
Another approach to consider
is actively engaging patients in
learning critical information, rather
than handing them a stack of
educational material to take home,
which can be overwhelming. UCLA
Health is creating a simplified
checklist for individuals to complete
before discharge, focusing on
when follow-up appointments will
occur, changes in medications,
the warning signs and symptoms
of their condition and who to
contact if worsening symptoms
occur, says Nasim Afsar-manesh,
M.D., associate chief medical
officer, assistant clinical professor
of medicine and neurosurgery
and executive director of quality
“It’s easy to say we’re following up with
patients, but are we actually doing it?”
Michael Henderson, M.D., chief quality officer,
Cleveland Clinic Health System, Cleveland, Ohio
and safety in the departments of
medicine and neurosurgery, at
UCLA Hospitals in Los Angeles,
Calif.
2. Establish better patient
follow-up
Follow-up is another key but
potentially overlooked component
of care that can help to reduce
readmissions. “It’s easy to say
we’re following up with patients,
but are we actually doing it?”
Henderson says. “If you’re making
follow-up appointments with
patients, are they also being helped
with their transportation needs?”
While conducting follow-up calls
at hospitals may be routine, tailoring
the conversation to a patient’s
specific condition is especially
valuable, says Lyons. Sacred Heart,
which calls all patients within 24
hours of discharge to confirm they
are filling their prescriptions and
to see whether they are having
difficulty understanding their care or
condition, recently created special
callbacks to those diagnosed with
pneumonia to discuss specific
symptoms because relapse of the
condition often isn’t obvious.
Tapping into community resources
can also improve patient follow-up.
In addition to having a case
management department that
works with patients to ascertain
whether they have the ability to care
for themselves after discharge, “we
have a county transition coordinator
who we can refer patients to [and]
who can assist with transportation
or other issues that occur once they
are home,” says Lyons.
Bringing follow-up care directly to
patients is another strategy hospitals
are using to reduce readmissions.
UCLA Health has partnered with
a community agency that uses
coaches to visit Medicare patients
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to review their care, schedule
appointments and teach them to
contact their physician to answer
questions about medications.
Through a recently implemented
program, the health system is also
trying to determine whether having
two nurse practitioners visit patients
recently discharged from skilled
nursing facilities reduces repeat
hospitalizations.
If budget allows, investing in
additional medical facilities for
patients to use after they leave the
hospital can also improve follow-up
care. For example, to provide
support during the vulnerable
30-day post-discharge period, UCLA
Health opened a new evaluation
and treatment center, which offers
more intensive services than a
primary care office and ensures that
“patients have a place to go before
they get into trouble and go to the
ER,” says Afsar-manesh. While
outcomes data aren’t available
yet, “anecdotally, we have faculty
who said they were sending
their patients to the emergency
department and instead sent them
to the center,” she says.
3. Embrace technology
Technology is increasingly helping
hospitals to track and provide much
of the information and education
patients need for their care,
which, in turn, may help to reduce
readmissions.
Specifically, much of
the logistics of patient
follow-up, such as postdischarge appointments
and medication
reconciliations, can be
coordinated through the
electronic health record,
says Afsar-manesh.
Adopting additional
technology, such as,
patient education
applications that providers
can use at discharge, may
also reduce readmissions.
Cullman Regional Medical
Center began using a healthcare
application that nurses can use
to pull up a discharge education
template based on an individual’s
medical condition and then
record themselves giving tailored
instructions to the patient.
Once patients are home, they can
listen to the discharge education
audio recording, as well as any
prerecordings about caring for their
condition via the phone or Internet.
Web users are able to access
additional audio and video files on
their condition and link to other
health information sites.
The medical application was first
tested in the 31-bed stepdown unit,
where patients with congestive
heart failure, acute myocardial
infarction and pneumonia receive
care. Within six months, the unit
experienced a 15 percent reduction
“We’re constantly engaged in preventing
readmissions.”
Nasim Afsar-manesh, M.D., S.F.H.M., associate chief
medical officer, executive director of quality
and safety in the departments of medicine and
neurosurgery, UCLA Hospitals, Los Angeles, Calif.
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Sponsored Content
Discharge Planning Essentials:
Reducing the Risk of Falls
medications may have entirely
new and unexpected side effects.
Amongst those sometimes
overlooked:
in 30-day readmissions, so the
center rolled out the technology to
other parts of the hospital.
4. Evaluate causes of
readmission
Whatever strategies hospitals
decide to implement, assessing
the reasons surrounding patient
readmissions can help centers to
further refine and develop their
programs.
Upon readmission, staff at
UCLA Health contact the patient’s
discharging physician and outpatient
providers to conduct a mini rootcause analysis, says Afsar-manesh.
“We ask, ‘What were some of
the things we could have done
differently for patients to keep them
healthy, and what do we need to do
to improve care in the future?’ We’re
constantly engaged in preventing
readmissions.”
Overall, hospital programs and
subsequent evaluations at UCLA
Health have resulted in an absolute
reduction of readmissions by 1 to 3
percent, according to Afsar-manesh.
“This doesn’t sound like a lot but
when you look at how challenging
it is to move the dial, this signifies
great strides,” she says. l
When preparing a patient for
discharge, it’s critical to take
every measure possible to set the
patient up for a successful return
to life at home. New or altered
medications must be explained.
Activity and/or diet restrictions
must be discussed. Durable
medical equipment may need to
be procured. In-home caregivers
may need to be arranged. But while
these are indeed important, it’s
often something much simpler that
causes discharged patients to return
to inpatient care: a preventable fall.
Falls are Common
Approximately one in three adults
over the age of 65 will experience a
fall each year. Yet only half of these
seniors will discuss the possibility of
falls with their healthcare providers1.
This risk increases dramatically when
medications are altered or new
physical restrictions are present.
Spending dedicated time discussing
falls prevention can help reduce the
risk of your patients experiencing a
potentially debilitating fall. Here are
some key considerations to cover.
Medications
Patients being discharged with
new or different combinations of
• rgency or Constipation:
U
Patients may rise and proceed
too rapidly towards a bathroom
when surprised by the need to
eliminate.
• ight Sensitivity: Newly lightL
sensitive patients may find
navigating familiar surrounds
surprisingly treacherous.
• rthostatic Hypotension:
O
Patients who feel normal while
seated may lose their balance
due to a quick drop in blood
pressure when they rise due to
this common side effect.
Environment
To best mitigate the risk of falls, the
home should be prepared for the
returning patient. Each room should
be surveyed to remove clutter
and tripping hazards. Grab bars in
bathrooms and railings for stairways
should be securely installed.
Here are some specific examples
to be implemented in the bedroom:
• repare a nightstand with room
P
for necessities that must be
accessed from bed. Clear the
floor of tripping hazards such
as shoes or slippers and lose
rugs. Provide a phone or Lifeline
device within easy reach.
Remove or place accessory
furniture in an out-of-the way
location. Provide a photo- or
motion-sensitive nightlight to
provide visibility during periods
of darkness. Secure any
electrical or device cords away
from areas of foot traffic. Finally,
locate any necessary DME
or assistive devices such as
walkers near enough the bed to
permit ease of use.
Lifeline
Unfortunately, not all falls or other
emergencies for which your patients
require assistance can be prevented.
Quick access to help in the case of
a medical emergency is the best
predictor of positive outcomes.
Lifeline with AutoAlert offers an
additional layer of protection for your
patients with advanced fall detection
technology that could save lives. The
AutoAlert pendant detects over 95%
of falls and can automatically place
a call for help if they are unable to
press their button.*
By empowering discharged
patients with information about
the changes they’re likely to
encounter, you’ll help set them
up for a successful return to their
homes. And when they do have an
emergency, they can feel secure
in the knowledge that Lifeline will
speed the appropriate help to them
as quickly as possible. l
H
ausdorff JM, Rios DA, Edelber HK. Gait variability and fall risk in community–living older adults: a 1–year prospective study. Archives of Physical
Medicine and Rehabilitation 2001;82(8):1050–6.
* ased on the number of undetected falls that have been reported to Philips Lifeline by U.S. AutoAlert subscribers for the period from January 2012
B
through July 2012. Undetectable falls can include a gradual slide from a seated position – such as from a wheelchair – which may not register as a fall.
AutoAlert does not detect 100% of falls. If able, you should always press your button when you need help.
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Improved Discharge Planning
Combats Patient Readmissions
By Joanne Finnegan
Two proven models help
patients stay out of the hospital
With the potential loss of
revenue on the line from
reduced Medicare payments
for higher-than-average
readmissions, hospitals are
putting resources and energy
into efforts to improve their
discharge planning and
transition case processes.
One way to prevent
readmissions—and avoid
Medicare penalties—is
to focus on patients’ care
after they leave the hospital
by improving coordination
between hospitals and other
care settings and community
services, and offering
enhanced patient education
and support.
Project RED checklist
means discharge tasks
not overlooked
There are a number of different
initiatives that hospitals can
use as models for their own
programs. One nationally
recognized initiative is Project RED,
the shortened name for Project
ReEngineered Discharge, which
targets preventable readmissions.
Boston University Medical Center,
an inner city teaching hospital,
developed Project RED to improve
care coordination around patient
discharge and reduce avoidable
readmissions. Funded by the Agency
for Healthcare Research and Quality,
Project RED focuses on patient
education while in the hospital,
as well as staff follow-up after
discharge to identify and resolve any
problems the patient is having that
could lead to a readmission.
Two major issues led the medical
center to undertake a study to
improve its discharge process—it
did not have a standardized way
of handling patient discharges and
the process was fragmented, says
Christopher Manasseh, M.D., a
researcher at Project RED. One
problem was that the medical center
did not assign specific tasks to staff
in charge of the patient’s discharge
process. For example, when it came
to providing education about the new
medications a patient had to take
“Bridge is a transition of care
model structured around social
work practices and theory.”
Madeleine Rooney, MSW, LCSW,
manager of transitional care for the
health and aging department Rush
University Medical Center, Chicago
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upon discharge, one staff member
might assume another already took
care of it.
The medical center came up
with a checklist that includes
12 components that staff must
complete. Those action steps
include scheduling follow-up
appointments and tests, arranging
for outpatient services, ordering
medical equipment, and confirming
medication plans. (See the list on p. 8).
Every patient has a discharge
plan that includes items, such as
medication reconciliation and postdischarge services coordination.
A nurse serves as the patient’s
discharge advocate and works with
the patient’s medical team. Patient
education begins as soon as feasible
after admission, says Manasseh.
Instead of one lengthy (and likely
overwhelming) session with a
patient, the nurse might talk about
the person’s diagnosis one day,
review medications another, and
hold a third session about proper
diet. The discharge advocate spends
an average of 90 minutes with the
patient during the hospital stay. At
discharge, each patient receives a
color-coded individualized instruction
booklet that also is sent to the
patient’s primary care physician.
The nurse reviews the instructions
and asks patients to repeat the
information and explain what they
are to do.
When a patient leaves the hospital,
the job is not finished. Originally,
Project RED used pharmacists
to make the follow-up calls to
patients to resolve any problem
with medications. Now the medical
center has the nurse discharge
advocate follow-up to identify and
resolve any problems. Within 48
hours to 72 hours, the same nurse
educator that the patient got to know
in the hospital calls to see how he or
she is doing. The nurse educator
also reinforces the education the
patient received as an inpatient,
Manasseh says.
“It’s basically the patient telling
you what he or she is doing,” he
says. But along with asking about
dialysis appointments or if a home
health nurse has visited, the nurse
also might ask about the patient’s
Chihuahua or grandchildren. The
phone call usually takes a good 15
minutes to 20 minutes.
“I think it is time well spent,” he
says, noting that the interventions
have helped the medical center
to reduce readmission by 30
percent. It has also seen a dramatic
improvement on patient satisfaction
scores.
When healthcare leaders learn
about Project RED, they often ask
if it can be implemented without
additional resources. “I say it’s
worth investing in this. The return on
investment is very high,” Manasseh
says.
A ‘Bridge’ between patients
and support services
While Project RED’s success has
been duplicated in other hospitals,
it is not the only model that works.
Bridge, a model used at Rush
University Medical Center (RUMC)
in Chicago, uses social workers
rather than nurses to provide patient
follow-up.
“Bridge is a transition of care
model structured around social
work practices and theory,” says
Madeleine Rooney, MSW, LCSW,
manager of transitional care for
the health and aging department
at RUMC.
In the Bridge model, social workers
coordinate post-hospital discharge
care for older adults. Efforts to
reduce patient readmissions at the
671-bed Rush begin at admission
and continue once patients go home
or to other care facilities.
At Rush, a team of five full-time
master’s-level social workers call
patients after discharge. They make
sure the patient understands his
or her plan of care. They ask if the
patient has made contact with a
specialist or how his or her rehab is
going, for example. They question
the patient about medications and
if the patient has filled his or her
prescriptions. They might ask if the
daughter who is supposed to help
at home has been available or if the
patient is anxious or depressed. The
social workers also ask the patient’s
caregivers about their stress.
The social workers coordinate
with all of the elements that make
up a person’s support system:
family, community agencies, church
communities and medical providers.
“Our ability to navigate obstacles is
part of what makes Bridge unique,”
Rooney says.
The social worker can stay involved
in a patient’s care and follow-up
for five days to 30 days or longer.
Each social workers takes on about
10 new cases each week and on
average each has about 12 to 15
cases open at a time.
“If not Bridge, there needs to be
some transitional model or system in
place that merges the inpatient and
outpatient world,” Rooney says. l
The 12 components
of Project RED
The following are the components of
a checklist that healthcare staff must
complete as part of Project RED:
Ascertain need for and obtain
language assistance.
Make appointments
for follow-up medical
appointments and postdischarge tests/labs.
Plan for the follow-up of results
from lab tests or studies that
are pending at discharge.
Organize post-discharge
outpatient services and medical
equipment.
Identify the correct medicines
and a plan for the patient to
obtain and take them.
Reconcile the discharge plan
with national guidelines.
Teach a written discharge plan
the patient can understand.
Educate the patient about his
or her diagnosis.
Assess the degree of the
patient’s understanding of the
discharge plan.
Review with the patient what
to do if a problem arises.
Expedite transmission of the
discharge summary to clinicians
accepting care of the patient.
Provide telephone
reinforcement of the discharge
plan.
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Q&A: How Baystate Mary Lane
Hospital reduced patient falls
by Joanne Finnegan
Hospital reports no
patient falls with
injuries in 2012 and
first quarter of 2013
The Agency for Healthcare
Research and Quality
estimates that each year
as many as 700,000 to one
FierceHealthcare: What is
Baystate Mary Lane Hospital
doing to prevent patient falls?
Tina Paulson: I don’t think we
have any unique strategies.
What we have is a committed
group of staff who don’t let
anything go. For instance, we
have a ‘no pass zone’ process
9
million patients fall in U.S. hospitals
and research indicates that nearly
a third of these mishaps can be
prevented.
Fall prevention, the AHRQ
states, requires an interdisciplinary
approach to care in an organization
that promotes teamwork,
communication and individual
where all call bells are answered
whether it’s your patient or not. In
the old days, it was ‘my side, your
side, my patient, your patient.’ So
we have taught all of our staff to
respond to all calls unless they are
with another patient at the time.
We are talking about rolling this out
through the entire organization. So
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expertise. One facility that has
successfully implemented such
a program is Baystate Mary Lane
Hospital, a 25-bed community
hospital in Ware, Mass., that is
part of Baystate Health. The
hospital has lowered fall rates in
both its critical care and medicalsurgical unit.
To uncover the secrets to
its success, FierceHealthcare
interviewed Nurse Manager Tina
Paulson, R.N., Linda Lechowicz,
personal care technician, and
Michelle Holmgren, public affairs
director, about the hospital’s falls
prevention program.
What we have is a
committed group of staff
who don’t let anything go.
when staff members see a call bell
ring, they will stop and ask what
they can do to assist the patient.
The other thing we have
implemented this year, much more
stringently than we have in the past,
is hourly rounding. So between
our patient care technicians,
our registered nurses, our case
managers and whoever else might
be on the floor, we are routinely
rounding on the patient. Every
time we are in there we’re looking
at fall risk areas, such as whether
they need assistance getting to the
bathroom or making sure they don’t
get up too quickly—whatever we
can do to anticipate their needs. We
also have patient boards in each
room. We have made sure that all
patients who use a safety device
of any kind—whether it’s a cane, a
bed alarm or a walker—we identify
that on the board. So anyone who
walks in the room knows how to
properly, safely ambulate or move
that patient so he or she is never at
risk at any point in time.
FH: Are there other things that
staff do?
Linda Lechowicz: We also have
an alarm program. If a patient with
a bed or chair alarm tries to get up,
a recorded voice asks the patient
to sit back down and use the call
light to get somebody to come and
help them. If we have a patient
that speaks a foreign language,
we will ask a family member for
help recording the message. We
try to anticipate patients’ needs by
paying attention to their toileting
pattern, seeing whether they want
to stretch their legs or go to the
bathroom before meals or if they
want to be walked or do some
other activity.
Paulson: A lot of our patients
might be a little confused, or have
dementia, or Alzheimer’s disease
and they tend to like to get up very
quickly. We might place them near
the nurses’ corridors so we can
watch them closely or we may use
sitters, which is a method we have
used in the past. We do have patient
care technicians who can sit with a
group of patients who are confused
or at fall risk.
You have to see it work. It’s
amazing. It comforts the patient to
just know that someone is there.
FH: How does the falls alarm system
work?
Holmgrem: My elderly motherin-law was a patient and I can tell
you the alarm program is so cool.
… In my mother-in-law’s case, the
recorded voice said, ‘Ruth, stay in
bed, we’re going to come in and
check you.’ When she started to
wiggle around, it automatically
addressed her urge to get out of
bed. Someone came in shortly
because the alarm went off, in
addition to that voice recognition.
Paulson: One case I remember
is where a gentleman just wanted
to hear that his dog was OK. So
we put his name on the recording,
and a message telling him his dog
was fine at home with so-and-so.
Knowing his dog was OK distracted
him and put him back in his chair.
You can personalize the message
for every single patient. You can
put their name, their nurse’s name,
maybe a special message. Whatever
is the reason they want to jump up
to get answers to, we relate it. The
You can personalize the
message for every single
patient. You can put their
name, their nurse’s name,
maybe a special message.
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or her button, a call to a Lifeline
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Personal Response Associate will
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fall risk. We put a pad under them
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whether they are in a bed or chair.
When you make the recording, you
want to say the patient’s name right
away. You want to stun them in the
first three seconds. You say their
name, identify yourself, ask them to
sit down and tell them you will be
right in.
FH: How do you identify a patient
who is at risk of falling?
Paulson: Some of it is by diagnosis
alone: for instance, a patient with an
altered mental status; anyone with
dementia or Alzheimer’s; anyone
with a neurological issue, such as
a stroke or weakness. Sometimes
it is based on age. But we have
a fall risk assessment that we do
every 12 hours on our patients. A
11 oc tober 2 013
In 2012, our general fall rate
was 2.26; the average for
our peer group was 2.89 falls
per 1,000 patient days. For
falls with injuries we were
at zero percent, while the
rate was 0.61 for our peer
group. … I’m proud to say we
are still at zero percent for
patient falls with injuries for
the first quarter of 2013.
certain score automatically tells
us they are a fall risk. We have a
list of different things that we do
in response. We lower the beds.
We put non-slip socks on all of
our patients. We always put signs
outside the door. We have signs
on the patient records. We have
care plans regarding falls. Everyone
gets the rounds. Those are all the
routine things. Someone who is at
much higher fall risk we probably will
cohort them and maybe they will be
assigned a particular personal care
technician to sit with that group so
he or she will be under much better
observation. You want that patient
closer, not at one end of the hall. We
have floor mats as well. If we really
do feel someone is a big risk, we
can put those all around the bed to
protect them in case the patient falls
out. We try not to restrain patients; I
can’t even think of the last time we
put a restraint on anyone at a fall risk.
Lechowitz: We call in family, also.
The family often says we should
call them if the patient is confused
or sundowning [Sundowning
fall is detected .
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*Based on the number of undetected falls that have been reported to Philips Lifeline by U.S. AutoAlert subscribers for the period
from January 2012 through July 2012. Undetectable falls can include a gradual slide from a seated position – such as from a
wheelchair – which may not register as a fall. ** Claim based on current number of subscribers.
continued on page 16
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12

7.
FierceHealthcare
FierceHealthcare.com
Integrated care: It’s Not Only
Possible, It’s Essential
By Alicia Car amenico
Two hospitals prove
multidisciplinary efforts lead to
better outcomes, lower costs
Efforts to control healthcare
costs and reduce utilization
requires all hands on deck-from all hospital departments
and service lines. The most
successful hospitals use
multidisciplinary teams to
integrate care for better outcomes
and lower costs.
One such hospital is Montefiore
Medical Center in the Bronx, N.Y.
Once it recognized that patients
who have behavioral health issues
on top of chronic illness have poor
outcomes and rack up significant
healthcare costs, it integrated
behavioral health and clinical care.
Montefiore, comprised of four
hospitals with 1,491 beds, formed
a team to support primary care
physicians that included a care
manager to educate patients and
perform necessary follow-up,
a behavioral health manager to
conduct onsite evaluation and shortterm psychotherapy, a psychiatrist to
provide individual consultations with
complex patients and psychotropic
medication management and
telephone interventions to lower
the cost of care, according to Henry
Chung, M.D., vice president and
chief medical officer, The Care
Management Company, Montefiore
Medical Center.
“There have been models out
there that are quite evidence-based
that have demonstrated that if
you use a team-based approach
… you can really impact both
medical outcomes and behavioral
outcomes,” Chung says.
Break down silos
“Integration needs to occur, even
if you don’t have initially the cost
outcomes data to support it.”
Henry Chung, M.D., vice president
and chief medical officer, The Care
Management Company, Montefiore
Medical Center, Bronx, N.Y.
13 oc tober 2 013
Multidisciplinary, integrated care
isn’t new but with the fragmentation
of healthcare services, it’s more
important than ever to coordinate
care, says Tom Lee, M.D., chief
medical officer at the South Bend,
Ind.-based healthcare consultancy
Press Ganey.
Thanks to integrated care efforts,
Sacred Heart Hospital in Eau
Claire, Wis., was able to reduce
fragmentation and break down its
silos. For instance, in its program,
daily patient rounds include the
doctor, nurse and therapist, who
together develop goals for each day,
according to Pat LuCore, assistant
administrator for Sacred Heart.
Similarly, its cancer program
holds conferences with pathology,
imaging, radiology, medical
oncology, radiation oncology, nurse
navigation and palliative care all
participating in the discussions. She
notes that having all the disciplines
work together has helped the
organization take all of the patient’s
needs into consideration.
While attending one of these
conferences, LuCore had what she
calls an “a-ha moment,” realizing
the multidisciplinary meetings
involve healthy discussion about
what is best for the patient. “That’s
a pretty wide gamut of disciplines
that are there all for the main goal
of developing what is truly the best
care for that patient.”
With similar goals in mind,
Montefiore’s integrated care
program involves nurse coordinators
in depression self-management and
social workers in the treatment plan
and monitoring chronic conditions,
according to Chung.
“From [the] patient perspective,
they don’t see it as ‘oh, the
social worker only cares about
the behavioral condition and the
nurse only cares about the medical
condition.’ No, everybody is caring
about the whole person and what
the total issues are to help them get
the best outcome possible,” Chung
says.
Overcome turf battles
It’s important to get multidisciplinary
healthcare professionals to work
closely with each other, but
overcoming turf battles can present
a challenge. So Sacred Heart
routinely schedules the meetings
to occur every two weeks around
physicians’ schedules. The team
also schedules the meetings on the
same day of the week and at the
same time so they can build their
practices around them.
The meeting schedule highlights
a key step to getting physicians
on board with care coordination
and integration efforts—removing
roadblocks that get in the way of
their day-to-day activities, according
to Press Ganey CEO Patrick T. Ryan.
Also, to get various disciplines
to play on the same team, LuCore
recommends identifying physician
and provider champions. Put
individuals who have a passion for
the service line on the integrated
care team, she says.
Be innovative and nimble
With multidisciplinary, integrated
care, Sacred Hospital has become
more nimble in its care delivery.
The industry is focused on
evidence-based medicine to drive
positive outcomes, but evidencebased guidelines can be limiting. To
adhere to these guidelines without
stifling innovation, hospitals must
use an integrated approach,
LuCore says.
For example, Sacred Heart’s
cancer program aims to adhere to
National Comprehensive Cancer
Network guidelines, but if a surgeon
doesn’t follow them, it can interfere
with the radiation and oncology
components of that patient’s care,
she explains.
Integrated care also can help
hospitals quickly shift patients to a
lower level of care when necessary.
For example, at Sacred Heart, a
multidisciplinary team that includes
a registered nurse, occupational
therapist, physical therapist, case
manager or social worker and a past
patient lead an information session
for patients and their significant
other, friend or family member prior
to joint replacement surgery to talk
about the upcoming procedure and
discharge plan. If the care team
recognizes flaws in the plan, having
everybody in the same room at the
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14

8.
FierceHealthcare
FierceHealthcare.com
same time allows them be more
reactive and responsive to changes
in the care plan and get the patient
the appropriate level of postdischarge care.
Being nimble and innovative is
essential, LuCore says, as there’s no
one answer to improving outcomes
and lowering costs. “Don’t be afraid
to go back to the drawing board,”
she says.
As Sacred Heart’s orthopedics
program added staff and clinicians
to a multidisciplinary team that
conducts patient rounds every day,
it had to change schedule times
so therapists, nurses, surgeons,
and discharge planners all could
join. The hospital also pulls in other
departments, such as pharmacy,
when needed.
Drive improvement efforts
As hospitals implement integrated
care programs, they won’t see costs
savings materialize for at least one
or two years, Montefiore’s Chung
notes. While evidence suggests an
average $2,000 savings per patient
after two years, he warns not to
launch integrated care programs for
the profits.
“We do a lot of things in medicine
because we know that it’s the
right thing to do and we want good
clinical outcomes, and good clinical
outcomes will ultimately justify the
approach,” Chung says. “Integration
needs to occur, even if you don’t
have initially the cost outcomes data
to support it.”
Sacred Heart’s LuCore echoes
those sentiments, urging hospitals
to keep the focus on the patient and
outcomes rather than finances. She
notes most people enter healthcare
because they want to take care
of people, but once you put dollar
signs on integrated care it becomes
just another cost saving initiative.
“That’s one of the benefits of it,”
she says, “but it’s not why you
would want to do multidisciplinary,
integrated care.” l
“Don’t be afraid to go back to the drawing
board”
Pat LuCore, assistant administrator, Sacred Heart,
Eau Claire, Wis.
continued from page 11
is a phenomenon associated
with increased confusion and
restlessness in patients with
dementia; often occurring in the
evening or while the sun is setting].
Sometimes we do a phone call or
sometimes they come in and talk to
them. That helps a lot.
FH: How do you know your efforts
are working?
Paulson: We have to report
to the Patient Care Links for
Massachusetts [a healthcare quality
and transparency collaborative
comprised of Massachusetts
hospitals, nursing leaders and home
healthcare agencies]. All of our
falls go into a database. In 2012,
our general fall rate was 2.26; the
average for our peer group was
2.89 falls per 1,000 patient days.
For falls with injuries we were at
zero percent, while the rate was
0.61 for our peer group. The data
we submitted for this year has not
been publicized yet. But I’m proud
to say we are still at zero percent for
patient falls with injuries for the first
quarter of 2013. Our current rate for
falls themselves is half of what the
peer group is. I feel very good about
our statistics.
are three key things a patient has
to know before he or she leaves
here. So we’ll teach on those three
things and then we want the patient
to repeat it back to us so they
understand it. So when patients are
a fall risk, I hear staff saying, ‘Ok,
we put everything in place. I don’t
want you getting up to go to the
bathroom. Don’t get up before using
your call bell.’ They repeat it and
repeat it.
FH: With hospitals concerned about
trying to prevent readmissions, are
there steps you take to prevent falls
when patients go home?
Lechowitz: I know the discharge
planner does work well with patients
and the patient’s family. They
often tell them, ‘Mom may need
more help at home’ or try to set up
services.
Paulson: If there’s an identified
need, such as a cane, a walker, a
commode or a bed, because they
can’t climb stairs or because they
need to be on the first floor or are
unsteady, we will order all that and
have it here before they go home.
We will not discharge them until the
equipment has arrived. … We go
over the different things to avoid at
home at admission, such as scatter
rugs and other tripping hazards. If
the patients still appear at risk when
they go home, and they are not
going to rehabilitation, we can print
out educational information and our
discharge plan that talks about falls.
FH: Are there any other strategies
you can share?
Paulson: Some facilities are doing
this and some are not. We do
have bedside handovers. So at the
beginning and end of every shift,
nurses go into the patient’s room
and introduce the oncoming shift.
We go over safety data, including fall
risk data. All of this together, done
routinely and consistently, makes a
difference. l
Lechowitz: I feel good on the floor
as a personalized care technician. It
means so much, especially for the
extra TLC of the patient.
FH: How do you extend your falls
prevention efforts to discharged
patients?
Paulson: We do a lot of education.
My office is right here on my unit, I
hear my staff all the time reiterating
lessons to patients. We use the
teach-back method. Maybe there
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